Open Access

Research
Prevalence and characteristics of prostate cancer among participants of a community-
based screening in Nigeria using serum prostate specific antigen and digital rectal
examination

Stephen Odunayo Ikuerowo1,&, Olufunmilade Adefolarin Omisanjo1, Muftau Jimoh Bioku1, Michael Olawale Ajala2, Victor Patrick
Nonyelim Mordi1, Julius Olusanmi Esho1

1
Lagos State University College of Medicine, Ikeja, Lagos, Nigeria, 2Lagos State Pathology Services, General Hospital, Lagos, Nigeria

&
Corresponding author: Dr Stephen Odunayo Ikuerowo, Department of Surgery, Division of Urology, Lagos State University College of Medicine 1-5
Oba Akinjobi Way, Ikeja, Lagos, Nigeria

Key words: Prostate, cancer, prevalence, screening, Nigeria

Received: 21/02/2013 - Accepted: 06/07/2013 - Published: 10/08/2013

Abstract

Introduction: Prostate cancer (CaP) is the most commonly diagnosed cancer among Nigerian men but CaP screening is not a common practice. The true burden of
the disease in Nigeria is not known. The study was aimed at studying the community burden of CaP in Lagos. Methods: During a community-based prostate cancer
awareness program in 13 local government areas of Lagos, men aged >40 years had serum total PSA (tPSA) test and digital rectal examination (DRE). Those with
abnormal DRE or tPSA >95th percentile of the cohort or both were selected for prostate biopsy (TRPB). Results: 4172 men were screened and complete data was
available for 4110 (98.5%). The mean age was 60.8 years. DRE was abnormal in 410 men and was significantly correlated with the age of the patient and tPSA
(p<0.001). The tPSA ranged from 0 to 438.3ng/ml with a median, mean and 95th percentile of 1.5, 2.5 and 10.0ng/ml respectively. 341 out of the 438(78%) men
selected were subjected to TRBP. Forty-three men had histological diagnosis of CaP, giving an estimated prevalence rate of at least 1.046% or 1046 per 100,000 men
of age ≥40. Only 11 (26%) had organ-confined disease while 17 (40%) had locally advanced disease and 15 (35%) men had metastatic disease. The majority of the
men, 32 (74%) were reported to have Gleason's score of ≥7. Conclusion: The prevalence rate of CaP among men aged ≥40 years in Lagos is higher than previously
reported in hospital-based study. Majority have advanced and high-grade disease.

Pan African Medical Journal. 2013; 15:129. doi:10.11604/pamj.2013.15.129.2489

This article is available online at: http://www.panafrican-med-journal.com/content/article/15/129/full/

© Dr Stephen Odunayo Ikuerowo et al. The Pan African Medical Journal - ISSN 1937-8688. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.

Pan African Medical Journal – ISSN: 1937- 8688 (www.panafrican-med-journal.com)

Published in partnership with the African Field Epidemiology Network (AFENET). (www.afenet.net)

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Introduction
There are contradictory guidelines by medical organizations on
screening for prostate cancer. The recommendation for prostate
cancer screening by the American Urological Association and the
American Cancer Society is for all men aged 50 years and above
with life expectancy >10 years and starting at age 40-45 years for
high-risked men (eg African Americans and those with affected first
degree relatives) [1, 2]. However, the National cancer Institute [3]
and the United States Preventive Service Task Force [4] do not
recommend screening for prostate cancer in the general population
or high risk individuals.
The objective of prostate cancer screening is to decrease morbidity
or mortality from the disease. However, there is currently no
conclusively acceptable evidence to establish whether screening for
prostate cancer actually achieves this objective. Prostate cancer
screening may reduce mortality from the disease almost by half but
with a substantial risk of overdiagnosis [5]. The European
Randomized Study of Screening for Prostate Cancer (ERSPC) also
demonstrated that population-based screening of men aged 55-75
years can reduce prostate cancer mortality [6,7]. Although
population-based screening has not been embraced at the moment,
individual patient testing or annual PSA testing is supported. There
is therefore no doubt that men should be given individual
opportunities take informed decisions whether or not to undertake
prostate cancer screening.
Prostate cancer is a leading cancer diagnosis and cause of cancer-
related deaths among men. It is the most commonly diagnosed
cancer among Nigerian men [8,9]. An estimated hospital prevalence
of 127 per 100,000 in Lagos, Nigeria was reported in 1997 [10]. A
recently published data from southwestern Nigeria also reported a
hospital prevalence rate of 182.5 per 100,000 male admission in the
hospital [11].However, the true prevalence in the Nigerian
community is not known. In the United States, prostate cancer has
been described to be more prevalent among the African-Americans.
The incidence of prostate cancer among White American men is
156.7 per 100,000 population compared with 248.5 for Black
Americans [12]. However, the incidence among the black African
community may be underestimated [13, 14]. In this study, we aim
to describe the prevalence and the characteristics of prostate cancer
among the participants of a community-based prostate cancer
awareness program that took place in Lagos, Nigeria with a view to
throw more lights into the status of the disease in the community.
Methods
A prostate cancer awareness program supported by the Lagos State
Ministry of Health was carried out in Lagos State, Nigeria. Local
Government Areas (LGA) were selected from the 20 LGA in the state
for the program which took place in 13 LGA in four batches.
Participants were recruited through public service announcements,
radio and television jingles and flyers in each of the 13LGA. Men
aged ≥40 years were eligible for the exercise.
At the various venues in the LGA, the participants had serum total
PSA test and digital rectal examination (DRE).Serum total PSA tests
were carried out on blood sample drawn before DRE and all
measurements carried out in a single laboratory of the General
Hospital, Lagos using chemi-luminescence immunoassay (Beckman
Coulter Access 2).The DRE were carried out by trained
professionals. Abnormal DRE, suspicious of prostate cancer, was
defined as present when the prostate showed any one or more the
following features; areas of hardness, nodules, surface irregularity
and asymmetry of the prostatic lobes.
The serum PSA results from all the 13 LGA were evaluated together
and the mean, median, 95th percentile values were determined.
Invitations for transrectal prostate biopsy were based on the serum
PSA and the DRE status. Men with serum PSA ≤4.0ng/dL with
abnormal DRE, men with serum PSA of >4.0 - 10.0ng/dL with
abnormal DRE and all men with serum PSA >10.0ng/dL (which was
the calculated 95th percentile serum PSA) irrespective of the DRE
status were subjected to transrectal prostate biopsy. Typically,
twelve cores of biopsies were systemically obtained and additional
samples were obtained from suspicious areas. All specimens were
subjected to histopathological examinations.
The data obtained was analysed using SPSS 19.0 for Windows
statistical software. Pearson's and Spearman's correlations were
used to assess parametric and non-parametric data respectively and
p values ≤0.05 were considered significant. The age of the
participants were categorized as 40-49, 50-59, 60-69 and ≥70
years.
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Results
A total of 4172men participated inthe awareness program in the13
LGA. The mean and median ages were 60.8 and 60 years
respectively. Data for serum PSA and DRE was unavailable for 13
(0.3%) and 25 (0.6%) men who refused either of the procedures
respectively. In addition, 24 (0.6%) men who were already on
medical treatment or urinary catheter for lower urinary tract
symptoms (LUTS) were excluded. Therefore 4110 (98.5%) men
were included in the final analysis. Table 1 summarizes the data
from the men who participated in the program.
The serum PSA values ranged from 0 to 438.3ng/ml with median
value of 1.5ng/ml and mean of 2.5ng/ml. The 95th percentile PSA
value was 10ng/ml. PSA values ≤4.0ng/ml were seen 3398 (82%)
men, values >4.0 to ≤10 ng/ml were seen in 414 (10%) men,
values >10ng/ml to ≤20ng/ml were seen in 194 (5%) men and
values >20ng/ml were seen 104 (3%) men. There was a significant
correlation between the serum total PSA and the age of the men
(p<0.001). Categorizing the age as 40-49, 50-59, 60-69 and ≥70
years, the median (and the 95th percentile) PSA were 0.8 (4.5), 1.3
(6.0), 1.6 (10.1) and 1.9 (13.4) ng/ml respectively (Table 1).
There were 410(10%) men who had abnormal DRE and the
distribution according to the age group is shown in Table 1. The
likelihood of finding a patient with abnormal DRE is strongly related
with the age of the patient (p<0.001) and the serum total PSA
(p<0.001). 270(66%)men with abnormal DRE also had serum total
PSA values greater the 95th percentile (10ng/ml) of the population.
Forty-four (13.7%) men with abnormal DRE have PSA values
greater than 4.0ng/ml but less than 10ng/ml.Only 3 (0.7%) men
with PSA value ≤4.0ng/ml had abnormal DRE.
Based on the serum PSA and DRE status, 438 (11%) men were
selected for transrectal prostate biopsy. Of these, 44 (10%) men
were based on abnormal DRE alone, 124(28%) based men on PSA
>95th percentile value (10.0ng/ml) alone and 270 (62%) men based
th
on both the 95 percentile serum PSA and abnormal DRE status.
Transrectal prostate biopsies were actually performed on341men
(78% of those in whom biopsy was indicated) who consented to it.
Of the 341 men who underwent biopsy, histopathological
examination showed that benign nodular hyperplasia (BPH) was
found in 242(71.0%), BPH with inflammation in 40 (11.7%), and
normal prostate in 16 (4.7%) men. Histopathological diagnosis of
prostate cancer was made in 43(12.6%) men. Therefore, the
estimated prevalence rate of prostate cancer in the entire cohort of
men was 1.046% or 1046per 100,000 men.
The clinical and pathological characteristics of the 43 men with
prostate cancer are presented in Table 2. All had adenocarcinoma
of the prostate. The serum total PSA were>10ng/L in 41 (95%) men
and >4ng/L to ≤10.0ng/L in remaining 2 (5%) men. Of the 43 men
with prostate cancer, 39 (91%) had abnormal DRE and the
remaining 4 (9%) had normal DRE. Further evaluation of the men
with prostate cancer showed that 11 (26%) had organ-confined
disease while 17 (39%) men had locally advanced disease and 15
(35%) men had the disease already metastatic to bones
(lumbosacral vertebrae and pelvic bones). The majority, 32
(74.4%), of the men were reported to have Gleason's score of 7
and above.
Discussion
Prostate cancer screening is not a common practice in Nigeria in
spite of prostate cancer being the most commonly diagnosed cancer
in Nigerian men [8]. Awareness about prostate cancer is also poor
[15, 16]. Majority of our patients therefore usually present in the
hospital with the disease in the advanced stage [11]. This
community-based testing for prostate cancer which was entirely at
no financial cost for the participants has given the opportunity to
create more awareness about the disease in the community. It also
helped to show the status of the disease in the community better
than a hospital-based study.
The estimated prevalence of prostate cancer in this cohort was at
least 1046 per 100,000 men of age 40 years and above. This value
is much greater than that previously reported in a hospital-based
study in Lagos [10] and appears similar to a report from Saudi
Arabia [17]. The prevalence rate is expected to be higher than what
has been obtained considering that only 78% of men in whom
biopsy was indicated actually had biopsy performed and that biopsy
was not performed on all men with PSA >4ng/dl. Although the men
in this study are community-dwelling, it may be possible that men
who have worries about their health are more likely to present.
What is of more concern however is the number of supposedly
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healthy men in the community who have advanced and high grade
disease and have not even sought for medical treatment of their Authors’ contributions
condition. Most men with prostate cancer in the cohort (74%)
already have advanced disease. This is in agreement with findings
SOI made substantial contributions to conception and design,
of Badmus et al in a hospital-based study from the same region of
analysis and interpretation of data; drafting the manuscript, revising
the country [11]. This is a very high figure when compared to only
it critically for important intellectual content. OAO, MJB, MOA, VPNM
4% of prostate cancer patients with metastatic disease at the time
and JOE made substantial contributions to conception and design,
of diagnosis in United States where PSA testing is a common
data collection, and revision of the manuscript. All the authors read
practice [18]. In addition, we also had 74% of prostate cancers with
and gave approval for the final version of the manuscript.
high grade disease based on the Gleason's score.

Widespread use of PSA testing may lead to the diagnosis of clinically

insignificant tumours and potential overtreatment leading to severe
Acknowledgments
morbidity and unnecessary healthcare cost. Performing transrectal
prostate biopsy for all the men with serum total PSA of 4 - 10ng/L We thank the Lagos State Ministry of Health for the funding of the
could have resulted in a few more cases of prostate cancer prostate cancer awareness program and the Staff of the
identified and therefore a higher value of estimated prevalence rate. Department of Disease Control of the Lagos State Ministry of Health
However, this would have led to a lot of unnecessary biopsy for the support during the fieldwork.
procedures for the majority of the men.

The normal range of serum total PSA values in our community is Tables
generally not known. Values ≤4ng/L are generally used as the
normal range. There are suggestions that African men may have a
Table 1: Serum PSA, DRE status and prevalence of prostate cancer
higher PSA value than what are generally accepted values for
among the participants of the programme classified according to the
Caucasian possibly because of a bigger prostatic volume or chronic
age group
prostatic inflammation [19]. In this study, the 95th percentile PSA
value was 4.5ng/L and 13.4ng/L for men aged 40-49 years and 70
Table 2: Characteristics of men with prostate cancer
years respectively, while the overall 95th percentile PSA value was
10ng/L. This may suggest that men in our environment generally
have a higher PSA value than their Caucasian counterpart.
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Conclusion
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Competing interests http://www.cancer.gov/cancertopics/pdq/screening/prostate/P
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The authors declare no competing interests.

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Table 1: Serum PSA, DRE status and prevalence of prostate cancer among the participants of the programme
classified according to the age group
Parameters Age (Years)
40-49 50-59 60-69 ≥70 ALL
N (%) 127 (3) 1827 (44) 1419 (35) 737 (18) 4110 (100)
Mean PSA (ng/dL) 1.3 2.0 2.7 3.6 2.5
th
Median PSA (95 percentile) 0.8 (4.5) 1.3 (6.0) 1.6 (10.1) 1.9 (13.4) 1.5 (10.0)

N (%) of men with PSA

≤4.0 119 (94) 1630 (89) 1118 (79) 531 (72) 3398 (82)
>4.0 – 10.0 7 (5) 121 (7) 172 (12) 114 (16) 414 (10)
>10.0 – 20.0 0 (0) 43 (2) 69 (5) 82 (11) 194 (5)
>20 1 (1) 33 (2) 60 (4) 10 (1) 104 (3)
DRE Status N (%)
Normal 124 (98) 1690 (93) 1250 (88) 636 (86) 3700 (90)
Abnormal 3 (2) 137 (7) 169 (12) 101 (14) 410 (10)

Referred for biopsy N (%) 3 (2) 145 (8) 180 (13) 110 (15) 438 (11)
Biopsy performed N(%) 2 (67) 118 (81) 126 (70) 95 (86) 341 (78)
Prevalence CaProstate N (%) 1 (0.79) 5(0.27) 26(1.83) 11(1.49) 43(1.05)

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Table 2: Characteristics of men with prostate cancer
Variable N (%)
Total 43 100
Age
40-49 1 2.3
50-59 10 23.3
60-69 24 55.8
≥70 8 18.6
DRE status
Positive 39 90.7
Negative 4 9.3
Serum PSA (ng/ml)
≤4.0 0 0.0
>4.0 – 10.0 2 4.7
>10.0 – 20.0 17 39.5
>20.0 24 55.8
Gleason’s score
≤6 11 25.6
7 20 46.5
8-10 12 27.9
Stage of disease
Organ confined 11 25.6
Locally advanced 17 39.5
Metastatic 15 34.9

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